The book under review provides a detailed criticism of the contemporary practice of psychiatry. It documents the unparalleled extent of the use of psychotropic drugs, their unacceptable risk, the irrational disease categories, and the lack of a proper evidence base. It traces meticulously the different ways in which the pharmaceutical industry influences professional guidelines through money, prestige, and scientifically corrupt means. This review provides an overview of the book’s arguments and recommendations and concludes with a comment on its scope and limitations.

Gøtzsche calls the professional leaders of psychiatry “silverbacks” (the term comes from the alpha male in a gorilla pack). He argues that the silverbacks’ authority in psychiatry makes the profession deadly for patients. Silverbacks also deny and defend through other means any critical examination of the profession’s structure, practice, and ethics.

In a key criticism of the Diagnostic and Statistical Manual (DSM) series, Gøtzsche argues that the DSMs have given up any analytical understanding of psychiatric illnesses and propose treatment using a symptom count. While this may be psychiatry’s salutary admission of its ignorance of psychopathology, the DSM philosophy functions in the twin fields of psychiatric biomedicine and pharmaceutical pressure. Gøtzsche argues that such a configuration facilitates overdiagnosis, the pathologisation of everyday normal conduct and disease mongering.

The author, being one of the key figures in the evidence-based medicine (EBM) movement, argues that drug development in psychiatry routinely does not meet the minimal requirements of EBM. The data is selectively represented, statistics wrongly interpreted, and the marketing of the drugs is based on misinformation.

Dealing with different psychiatric “illnesses” like depression, anxiety, attention-deficit hyperactivity disorder (ADHD), and schizophrenia, Gøtzsche undertakes a detailed examination of the evidence, published clinical trial outcomes, and critical analyses of the conclusions. He argues at length how dangerous psychotropic drugs used for these diseases are.

Gøtzsche argues that in nearly every case, psychotherapy has proven to be consistently better in its outcomes than the use of psychotropic drugs. More, the use of psychotropic drugs is effective only when accompanied by psychotherapy. However, Gøtzsche asserts, the psychiatric profession likes to take the easy way out by eliminating the psychotherapeutic engagement completely.

The author says that the book is written for the lay person who is confronting psychiatry as a user or carer, and also for young psychiatrists who are thoughtful enough to question the norms of mainstream psychiatry. However, this reviewer feels that there is an excess of scientific evidence-based argument in the book, and that some of the statistics is too advanced. Both these may discourage lay reading.

It should be clear from this very sketchy summary that this is a polemical book written against the viewpoint of psychiatry and the use of drugs, ECT, and any form of coercion to “cure” the mentally ill. This leads to predictable resistance from the discipline. For example, on the one hand, if the book argues that psychiatry does not have adequate evidence base, it could be argued in turn that psychoanalysis was completely speculative and had no evidence base at all. On the other hand, it could be argued that EBM’s standards of statistically valid evidence delegitimise psychotherapy’s individualised approach as ineffective, irrational, and unacceptably resourceintensive.

This reviewer feels that there is an inadequacy in using a scientific evidence base alone to deal with the most fundamental problems of psychiatry. Psychiatry is the rational study of methods to “cure” “irrationality” or madness. Thus, the discipline assumes that the single norm of life is rationality and effective functioning in society. The idea of an evidence base is, according to Archie Cochrane, nothing but the statistical assessment of the efficacy and effectiveness of medical care, ie, its economy and biomedical usefulness. The evidence base put together by Gøtzsche for his analysis follows scientific rationality that seeks to correct the perspective of the psychiatrists themselves. Such a rationality, however, strikes at the root of irrationality and incoherence, which form an integral part of “mental illness” as defined rationally. Such a statistical rationality cannot admit as evidence the individual experience that seems to characterise the distress of the mad. Gøtzsche is thus driven by a model of rationality that is structurally opposed to the mad experience.

This form of criticism is forced to ignore other forms of evidence because the mainstream does not treat them as evidence – autobiography, narratives of the mad experience, accounts of being severely disabled by distress, etc. This is because they do not meet the statistical criteria of objective validity. However, this reviewer would argue strongly that such forms of evidence are crucial for a comprehension of the mental equilibrium or lack thereof of the one who is undergoing the experience/terror of madness. Further, what if the definition of cure offered by the discipline of psychiatry is not acceptable to the mentally distressed? What if the mad begin to see madness as a form of disability that should be included and accommodated by design in social structures without constraint or coercion, as are other disabilities? What if he or she wants to learn to live with the pain and the vision that madness makes possible?

The mad movement (broadly characterising the multitude of resistance movements by one politically acceptable name) across the world is asserting this right to live without being subjected to what is experienced as the coercive model of modern society. It is not that the mad always want to reject treatment, but that the treatment should not involve chemical, physical or worse, electrical restraint. They feel that being treated by biomedical psychotropic drugs is currently the equivalent of dulling the mind, imprisoning the body, and killing the spirit (to use derelict but strangely empowering categories). Their argument and plea is that it should rather heal the mind, body, and most importantly, spirit. This much Gøtzsche would surely agree with. The insurmountable difficulty however lies with trying to prove this case using rational models.

It is not this reviewer’s intention to ask why Gøtzsche wrote this book about psychotropic drugs, psychiatry, and the pharmaceutical industry rather than about the developments and insights of the mad movement. Nor is it to insist that all persons in mental distress rebel against psychiatry and psychotropic drugs, and hence, that the book is a wasted effort. However, a peep into the broader political struggles around madness shows how marginal the mentally dulling world of rational psychiatry is to the emerging imaginative arguments of mad politics about disability, law, development, community assistance, recovery, and life. It is certainly a hope that these exciting horizons, even if currently cherished and nurtured by a small minority, will help transform this century’s experience of madness completely.

Acknowledgements

I would like to acknowledge that this review is informed by the breathtaking perspectives of mental health and disability struggles I was privileged to witness in the recent seminar “Mental health and development: disseminating Bapu Trust Research”, held at Pune on March 18 and 19, 2016. I remain deeply indebted to Dr Jayasree Kalathil, of Survivor Research, UK, for her invaluable guidance and insightful orientation. I would also like to acknowledge with much gratitude the inputs, moderations, and opinions shared readily by Professor KS Jacob, Christian Medical College, Vellore. Errors and excesses are mine.